CL question: Opiate dependence in inpatient medical patients

[m1345]

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As a PGY-1 on inpt medicine rotations, I've been thinking a lot about what the right thing to do is when patients with opiate dependency are admitted for a medical condition but their withdrawal is so severe that they are considering leaving AMA. It seems like everyone on the psych CL service has a different view of what to do. Obviously it is ideal to just stick with clonidine/immodium/etc, but what do you do when that isn't enough?

I think a huge part of the issue is that there are not enough suboxone providers or spaces in the methodone clinic to be able to transition the patient to after discharge...I don't like treating their withdrawal with methodone (or suboxone, which some psych cl folks have recommended..) and then sending them out to withdraw on their own, especially when they are expressing an interest in getting treatment for their dependence. But I also find it wrong to let someone with endocarditis leave AMA just bc we don't want to treat their withdrawal...

What do you do at your institution? Are there any guidelines addressing this issue?

 

[notdeadyet]

These are good questions to ask. It's a testament to you that you're considering this kind of thing while on a medical unit. It often goes over a lot of folks heads.

A couple of thoughts:

- Be sure to distinguish between withdrawal and addiction. On an inpatient medical unit, it's much easier to treat the former than the latter. And distinguishing between the two when considering a patient who wants to leave AMA is important for several reasons. If you've established that a patient is in withdrawal and wants to leave AMA, you need to consider whether you're treating the withdrawal symptoms adequately and also whether or not the withdrawal symptoms are sufficient that the patient meets criteria for an involuntary hold. If you've established that the patient wants to leave for reasons of addiction, it's a different ball game and your options are limited. You can sufficiently treat a patient's withdrawal symptoms and they can still be very set on leaving AMA because of the strength of their addiction.

- If you've established that a patient's withdrawal symptoms are undermanaged, you are right to consider this in your treatment plan for ethical reasons as well as medicolegal. You can consider opiate replacement, but in a pain-free case (meaning, one in which the patient is not on a scheduled or PRN opiate use for pain management), this is going to be a controversial approach. You can consider methadone and suboxone, but you're right that this is likely only going to get them through withdrawal while on an inpatient until. Bridging them to a methadone clinic or suboxone provider might not be realistic on your locale (probably not in many-to-most).

I'm probably just muddying the waters, but I'm hoping this might help paint why you're likely not going to get a good consensus among your team. It's not that you're missing anything or that they are, necessarily, it's just that it's a pretty complicated situation.

 

[michaelrack]

and also whether or not the withdrawal symptoms are sufficient that the patient meets criteria for an involuntary hold.

Committing for substance abuse/withdrawal is controversial. Withdrawal isn't usually dangerous except for benzo's/sedatives/alcohol. Also, I think there can also be some dangers in pregnant pts undergoing opioid withdrawal. Agree with most of your other thoughts.

 

[notdeadyet]

Committing for substance abuse/withdrawal is controversial. Withdrawal isn't usually dangerous except for benzo's/sedatives/alcohol.

True. I wasn't thinking about danger-to-self as much as someone walking out when they should be placed on a gravely disabled or medical hold.

Valid points though. I've only really seen nasty holdable ETOH withdrawal. The opioid withdrawal symptoms I've seen have been kind of underwhelming from an acute psych perspective.

 

[nitemagi]

It's a good question, and one that really raises other questions, as to our role on a consult team -- making the best recommendations for the patient, or just answering the consult question.

Ultimately it comes back to the risk/benefit ratio for me.

Is it worth trying to push the person through basically a detox period, when that isn't their reason for hospitalization? What if they are so against it that leaving AMA means they might lose their life? Is it worth enabling an addiction temporarily to save them from a life threatening condition? Sometimes, I think so, if one can keep the whole picture in mind. I was trained in a relatively rigid model which I can see the point to, but may lose the forest for the trees.

It's best to try to get the pt's buy-in to get through a detox, if possible. If it's for a greater purpose, they may be more willing to put up with some suffering. This is where using your therapy skills comes into play.

 

[splik]

agree with above - you need to treat withdrawal, and realize that while you should engage in conversations about change/addiction, you are likely not going to be treating opiate addiction on a medical floor, and it is very likely that your patient may not be ready to change. Be as aggressive with supportive therapy (i.e. as much clonidine etc that he can tolerate) first, and if that is still not enough, then although controversial I don't think it is unreasonable to give methadone, and I even have given PRN dilaudid on occassion. You have to be able to justify in your head that the patient has a serious medical condition that needs urgent treatment, and that using opiates in this way is in the patient's interest. In the case of endocarditis, it probably is - though given the length of stay woild likely be more than other conditions you would want to be tapering off this, and more kindly treating withdrawal.

Sometimes the pharmacists will balk at using opiates like this, but given hyperalgesia is a significant component of opiate withdrawal, you can probably easily make the case for treating pain (which is the only legitimate way you are going to be starting methadone here).

You need to clarify the goal in your head. It is first and foremost to be able treat the patient's endocarditis, which mean treating the withdrawal. Getting the patient some sort of addiction treatment is all well and good, but is not the primary goal and there is good chance you will be unsuccessful in this regard.

 

[SeniorWrangler]

You may want to check with your institution. Some hospitals have specific policies against detoxification with opioid agonists. This has been known to have a "magnet effect" on the local opioid-dependent population, who may seek inpatient admissions in order to get the relatively painless detox instead of going cold turkey. It would be nice to be able to get selected addicted patients started on methadone or suboxone and refer them seamlessly to outpatient addiction treatment, but I don't know how to do it.

 

[strangeglove]

There is really very little harm in detoxifying someone hospitalized for a medical reason with methadone, as long as it is done correctly/safely. No need for any special waiver. You are not "transitioning" them to methadone. The idea of detox is to taper off the methadone, not maintain it. Thus, you are not required to refer them to an outpatient methadone program after they are discharged, though this could something you arrived at while treating them, if they decided to maintain methadone, rather than detox. If the patient detoxes using methadone and they decide at discharge that they are not interested in any treatment, you have not exacerbated their illness; you have only prevented their suffering for the brief time they are in the hospital, not to mention the suffering of everyone who is taking care of them. They can always start using opioids on the street after discharge if they experience withdrawal after discharge, which is unlikely if the detox is done properly. They will be no worse off for having been detoxed using methadone. All of the above also holds for detoxing using Suboxone, except the doctor prescribing the Suboxone usually does require a DEA waiver.

Above all else, be aware of the countertransference that the primary team - not to mention the consulting psychiatrist - have toward these patients, and how this is determining their treatment decisions. This can, for example, cause certain doctors or even entire units to develop "policies" that they will only detox patients using clonidine, etc. There is often underlying such policies a desire to punish these patients for their bad behavior. That is fine to do if you are the police, but it is not our role as doctors.

So what if patients want a "painless detox"? I for one would prefer that patients come to my hospital to get a painless detox than continue to use opioids on the street while suffering from a medical problem. If you are talking about faking/malingering a medical illness in order to get detoxified on a medical floor, few addicts do this in my experience, since they can get "painless detox" elsewhere without all of the hassles of dealing doctors who don't know what they are doing and also tend to hate them as patients. And if someone "slips into" a medical unit who is malingering without a true medical illness, but who actually wants to get detoxed, then that's a real opportunity to help this person possibly stay off opioids for longer than they anticipated when they came into the hospital. It's the job of the consultant to try to understand why this person, at least for the moment, wants to stop using opioids, and work with that motivation, i.e. motivational interviewing. If you are worried about "wasting" valuable hospital beds on these patients (as many doctors are), consider that their opioid dependence, if untreated, will cost quite a bit more in terms of hospitalizations for infections, overdoses, suicide attempts, gunshot wounds, etc.

 

[BobA]

x

 

[BobA]

There is really very little harm in detoxifying someone hospitalized for a medical reason with methadone, as long as it is done correctly/safely. No need for any special waiver. You are not "transitioning" them to methadone. The idea of detox is to taper off the methadone, not maintain it. Thus, you are not required to refer them to an outpatient methadone program after they are discharged, though this could something you arrived at while treating them, if they decided to maintain methadone, rather than detox. If the patient detoxes using methadone and they decide at discharge that they are not interested in any treatment, you have not exacerbated their illness; you have only prevented their suffering for the brief time they are in the hospital, not to mention the suffering of everyone who is taking care of them. They can always start using opioids on the street after discharge if they experience withdrawal after discharge, which is unlikely if the detox is done properly. They will be no worse off for having been detoxed using methadone. All of the above also holds for detoxing using Suboxone, except the doctor prescribing the Suboxone usually does require a DEA waiver.

Above all else, be aware of the countertransference that the primary team - not to mention the consulting psychiatrist - have toward these patients, and how this is determining their treatment decisions. This can, for example, cause certain doctors or even entire units to develop "policies" that they will only detox patients using clonidine, etc. There is often underlying such policies a desire to punish these patients for their bad behavior. That is fine to do if you are the police, but it is not our role as doctors.

So what if patients want a "painless detox"? I for one would prefer that patients come to my hospital to get a painless detox than continue to use opioids on the street while suffering from a medical problem. If you are talking about faking/malingering a medical illness in order to get detoxified on a medical floor, few addicts do this in my experience, since they can get "painless detox" elsewhere without all of the hassles of dealing doctors who don't know what they are doing and also tend to hate them as patients. And if someone "slips into" a medical unit who is malingering without a true medical illness, but who actually wants to get detoxed, then that's a real opportunity to help this person possibly stay off opioids for longer than they anticipated when they came into the hospital. It's the job of the consultant to try to understand why this person, at least for the moment, wants to stop using opioids, and work with that motivation, i.e. motivational interviewing. If you are worried about "wasting" valuable hospital beds on these patients (as many doctors are), consider that their opioid dependence, if untreated, will cost quite a bit more in terms of hospitalizations for infections, overdoses, suicide attempts, gunshot wounds, etc.

Completely agree. A 3-day methadone taper is the humane thing to do, and not necessarily painless depending on how much they've been using.

If I'm seeing someone in the ER and it's clear they are going to have a nasty detox, I usually try to get them to one of the local detox/dual diagnosis units

 

[vistaril]

You may want to check with your institution. Some hospitals have specific policies against detoxification with opioid agonists. This has been known to have a "magnet effect" on the local opioid-dependent population, who may seek inpatient admissions in order to get the relatively painless detox instead of going cold turkey. It would be nice to be able to get selected addicted patients started on methadone or suboxone and refer them seamlessly to outpatient addiction treatment, but I don't know how to do it.

completely agree....if you are the go to hospital for using methadone/suboxone/another opiate taper, then the hospital/psych ward will be flooded with self pay(ie no pay) opiate dependent patients who have run out of money to buy opiates and need help to avoid withdrawl. Now that's not to say a hospital shouldn't do some of that, but you have to do it selectively. Just like a plastic surgeon might devote 5% of their time to true no pay charity cases, a hospital/psych ward/detox units may want to devote a very small number of beds towards this mission for this population and use it very sparingly(obviously you would have to turn most people away and it may seem arbitrary who gets in and who doesnt).

For patients with resources, there are numerous inpatient substance treatment centers who will be happy to detox them with suboxone/opiates/methadone. They require money and insurance + money, but hey, thats the way the world works. Some communitites have more resources for this population than others in terms of charity care detox options.

 

[CounselortoMD]

completely agree....if you are the go to hospital for using methadone/suboxone/another opiate taper, then the hospital/psych ward will be flooded with self pay(ie no pay) opiate dependent patients who have run out of money to buy opiates and need help to avoid withdrawl. Now that's not to say a hospital shouldn't do some of that, but you have to do it selectively. Just like a plastic surgeon might devote 5% of their time to true no pay charity cases, a hospital/psych ward/detox units may want to devote a very small number of beds towards this mission for this population and use it very sparingly(obviously you would have to turn most people away and it may seem arbitrary who gets in and who doesnt).

For patients with resources, there are numerous inpatient substance treatment centers who will be happy to detox them with suboxone/opiates/methadone. They require money and insurance + money, but hey, thats the way the world works. Some communitites have more resources for this population than others in terms of charity care detox options.

My former employer, a freestanding psychiatric hospital (i.e., NOT detox; NOT rehab), had developed a very clear reputation within the community as a facility that would essentially admit patients for opiate detox--then somehow classify it as "primary psychiatric treatment", and ultimately find a way to obtain authorization/payment from their HMOs (mostly these were a variety of managed Medicaids from several local states, which we gladly accepted as our bread-and-butter source of income).

Anyway, I think there is little doubt that we provided an important and highly-demanded service to our community--but from an ethical standpoint, our standard practice (of creating white lies to justify inappropriate admissions) was extremely dubious. After a while, even the patients and their family members had figured out the secrets behind our little system of deception: "Oh, I guess you need me to say I'm SUICIDAL so I can stay here"; "Of course I don't feel safe taking him home, he always threatens to kill me when I won't give him drug money!"; "Last night I wished that I would die when I sniffed two bundles of heroin at a party"; "If I can't get more pills, I would probably want to kill myself"; "I guess I might cut my wrist if you don't have a bed for me." I could go on...

Furthermore, if a patient couldn't produce the magic words on their own, then of course it was the counselors' job to explain our criteria for admission (i.e., to coach the patient through what they needed to say in order to be admitted). Naturally, we never mentioned to the insurance companies that such information had actually never arisen spontaneously from the patients' own thoughts.

I know it might seem like only a matter of semantics. However, I can assure you that at the end of the day, it just didn't feel like the right thing to do.

 

[dozitgetchahi]

As a PGY-1 IM resident with a side interest in addictions medicine, I've been seeing a lot of these issues on inpatient wards at our county hospital as well.

The big problems that I've been dealing with are these...

-Our psych residents don't rotate at our county hospital - they only cover the VA and our two university hospitals. The county psych consult service is a handful of burned-out psychiatrists who are completely overwhelmed by the consult volume...thus, unless your pt is floridly psychotic or manic, the answer from them usually is 'you're on yer own, boy'.

- IM hospitalists tend to have a good handle on managing alcohol detox but very little awareness/knowledge of opioid detox and/or addictions management. When I was all cued up to order a fairly standard opioid detox protocol on one of our withdrawing pts, my attending was like 'wow, you know more about this than I do'. Specifically, the idea of using clonidine to help manage opioid withdrawal symptoms was almost totally foreign to some of these attendings.

- Because of this, it's easy for the attendings to get caught in crazy catch-22s:

=> 'Wow, our pt has horrendous endocarditis but might leave AMA because of withdrawal. I guess we should try to treat this' => 'Damn, psych won't help us' => 'I don't think we can legally use methadone/Suboxone since we're not licensed for it' => 'Let's try to cover him with morphine/Dilaudid' => 'Wow, it takes a LOT of morphine/Dilaudid to cover these symptoms in somebody with a badass heroin habit...maybe we shouldn't be doing this' => "Hmmm, now I donno what to do'.

- Lastly, our outpatient addictions service (understandably) got fed up with doing inpatient consults on people who had no actual desire to get clean, so now they tell us that the patient has to be discharged first and has to call them of his/her own volition to get set up with them. Our pts rarely, if ever, follow through on this - and I feel like I've lost more than a few pts who might have gone through with doing what they needed to do if someone had actually seen them before they left.

 

[whopper]

Committing for substance abuse/withdrawal is controversial.

In some states it's illegal.

In Ohio, I'd say it's illegal. Per Ohio's laws you can only hold someone if they're dangerous, due to a disorder of "thought," "mood," "perception," or "memory." If the person wants to leave because they want a hit of something and could have a seizure, from say benzo withdrawal, you can't hold them against their will. There is no disorder in the categories mentioned above. If the patient is warned of the risks and still wants to leave and understands the risks, that's even worse in terms of crossing the law.

A problem with psychiatrists interpreting laws is they often break it into "does the person have a mental illness?" and "are they dangerous to themselves or others?" While all states follow those guidelines, the devil is in the details. If you actually read the laws in several states, substance abuse/dependence doesn't count because it's not considered a mental illness where one could be involuntarily held.

 

[billypilgrim37]

If the patient is warned of the risks and still wants to leave and understands the risks, that's even worse in terms of crossing the law.

Not infrequently, this is the crux of the matter though, as many folks in the hospital going through withdrawal develop a delirium and DON'T understand those risks and are agitated and not cooperative with a capacity evaluation. The way we interpret things locally, it becomes a matter not of an involuntarily hold, but whether the person has the capacity to make the decision to leave the hospital. If they don't have capacity to make that decision, then they can't make that decision, so they can't leave. If they do have the capacity, then definitely, you can't hold somebody for substance use or terrible judgment.